Health Care: Who Cares?

Is health care any less directly threatening to our way of life, individually or collectively, than the frolics of depraved dictators?

I can’t think of any subject I write about that gets a smaller response than health care. I have more earned credentials and years of experience in this area than in running the world. So, why the well of silence this subject falls into?

The complexities of medicine or medical economics are not more difficult than war or foreign trade. The personal experience we have with health care, indeed, should make this subject more open to understanding.

The simple answer to my question is that, for the overwhelming majority of Americans and commentators, the health care system we have developed basically works. Almost all are one way or the other cared for, and by the most readily accessible, most advanced, and highest quality health care in the world.

Most criticism comes from three areas: The first is almost a relic of decades ago, when the poorest and eldest among us had difficulties of access. Medicaid, Medicare, required emergency care, pharma’s targeted prescription discounts on those most at risk and unable to pay, have largely made this concern an old chestnut for the American Left right up there with “Workers of the World, Unite!”

The second source of criticism is more pressing. At the rate we’re going, health care spending is increasingly crowding out other priorities from personal and government budgets. Increased access, medical advances, and an ageing population are most of the cause. These expense-drivers are not going away. So, instead, critics from the Left distract with another old chestnut, private health care costs more than a nationalized system, ignoring that what small difference there is comes at the cost of bureaucratic rationing and of free-riding on most of the costs of advancing technology and drug development by the United States.

The third source of criticism comes from the Right, that a serious expense-driver is we use too much health care out of ignorance and buffering from personal responsibility for choices. There’s some truth to this, but it is either exaggerated or rests on tenuous evidence. More important is that overall national expenditures for health care will increase, and that cannot be allowed to deny us more critical public goods that only government can provide or to cripple the job and wealth creating competitiveness of American business.

I usually see individuals and employers choosing health plans with an eye on the premium, but that is only part of a more or less formal analysis of risk-reward between acceptable levels of insurance and outlay. There is a well-developed appreciation, fact-based, that the overwhelming source of medical expense comes from difficult to predict catastrophic illnesses and accidents, not from routine and preventive medicine. There is a well-developed appreciation that routine and preventive medicine is key to avoiding many catastrophic events and costs.

Employer-provided health insurance is blamed for its paternalistic choices or its subsidies removing many from more direct self-responsibility. Yet, I’ve never seen an employee with more knowledge of the choices than the employer who studies alternatives, or the collective decision-making that usually occurs in smaller employers.

With all that said, then, what is President Bush trying to do with his health care initiatives?

He is not entertaining a laissez faire chestnut that all individuals should be solely responsible for their own choices and health care, with government totally out of the equation. That ideological direction, as emotionally appealing as it may be to some, is just not realistic.

Daniel Weintraub presents analogies of self-responsibility for our food, housing and auto choices as compared to either government-run or mandated health care or employer-provided insurance. However, the differences between the catastrophic consequences, costs and levels of standardized information available related to health care choices are of a different kind and dimension from selecting among nutrition, residence or transportation alternatives.

So, Weintraub realizes increased choice not less, with government support where necessary is more in line with health care.

Individual choice. Individual responsibility. Voluntary transactions. And targeted help for the few who cannot afford to buy what they need on the wages they earn, with the burden of financing that assistance falling on all of society, not just on a few.

President Bush is trying to increase our choices and provide us with the information to make better choices. This is, essentially, a rather modest goal, particularly when put aside the alternative of government-run health care with all the proven pitfalls or just continuing down the path of unsustainable employer-provided health care arrangements. These grew out of World War II era schemes to end-run wage-controls and the post-WWII union-led enlargement of those arrangements. As with modernizing Medicare past its 1965-model, it's time to modernize private health care past its World War II and 1950's model.

The only realistic alternative is the shifting of more choice and costs of health care back to individuals, at least those who can afford them and benefit from more useful information. This portion of the population, at least, ought to make choices between their own necessary health care and expensive restaurants, 6000 square foot houses, and luxery cars.

For example, working with the American Medical Association to develop widely disseminated statistics of quality of care by providers will increase the ability of consumers to choose cost-effective care.

As President Bush said the other day:

First of all, we've got to choose between two competing philosophies when it comes to health care. Behind all the rhetoric in Washington, and all the proposals, there's really a philosophical debate. On the one hand, there's some folks who…believe that government ought to be making the decisions for the health care industry. And there are some of us who believe that the health care industry ought to be centered on the consumer.

Greater individual responsibility for choices and costs is preferable to increasing government debts, crowding out education or defense or roads, or to destroying the economic competitiveness of American business.